SYMPTOM CONTROL FOR ADVANCED RESPIRATORY DISEASE

Dr Sharon Chadwick HOSF 2012

SYMPTOM CONTROL FOR ADVANCED RESPIRATORY

DISEASEDR SHARON CHADWICK

CONSULTANT IN PALLIATIVE MEDICINEHOSPICE OF ST FRANCIS


COPDPulmonary fibrosisBronchiectasis Pulmonary hypertension Cystic fibrosis

WHICH DISEASES?


SymptomsSYMPTOM COPD FIBROSIS

Dyspnoea +++ ++++

Anxiety ++++ ++++

Depression +++ +

Immobility +++ ++++

Fatigue +++ +

Pain +++ +

Constipation +++ +

Nausea + +

Oedema ++ +

Dry mouth ++ +

Insomnia ++ ++


KEY CONSIDERATIONS IN COPD

Often have high anxiety levels

Frequent fliers May have osteoporosis Think about reduction

in doses of nebulisers Need to assess relative

contribution of anxiety/pure dyspnoea


KEY CONSIDERATIONS IN PULMONARY FIBROSIS

Rapidly progressive disease Catastrophic dyspnoea Cough sometimes problematic May affect younger patients Highly likely to require morphine/midazolam

at the end of life for symptom control

PLEASE CONSIDER PALLIATIVE CARE REFERRAL


Optimise medical management Pulmonary rehabilitation Oxygen assessment Non-pharmacological

◦ Breathing control/relaxation◦ Pacing◦ Hand held fan

Pharmacological◦ Opioids◦ Benzodiazepines

Breathlessness


Is the breathlessness worrying the patient? Is the problem primarily breathlessness or

anxiety? Are current interventions being used

appropriately?

Breathlessness


Breathlessness

Anxiety◦ Explore reasons ◦ Consider

benzodiazepines (lorazepam 0.5mg od)

◦ CBT

Breathlessness◦ Explore triggers◦ Encourage pacing◦ Consider morphine

(2.5mg od)

May need to use both in some patientsSTART LOW, GO SLOW!!


Psychological issues


Anxiety Fear of the future-fear of dying, fear of

being dead, worsening symptoms, loss of independence, concern for the carer, financial issues

Failure to adjust to loss of function, feeling of should be doing more

Reluctance to use oxygen out of home environment and to use wheelchair.

Reluctance to ‘give in to the illness’



Acknowledge difficulties Explain benefits of doing things differently Explore ways that things might change and

look different Giving the patient control

‘A different way to fight the disease’



A Holistic Approach

Use of CBT techniques◦ Stop negative thoughts◦ Pleasure vs mastery◦ Goal setting◦ Life grid◦ Diary


When to think palliative care Advanced respiratory disease with complex

physical, psychological, spiritual or social problems

Continued severe symptoms despite optimal medical management

Repeated hospital admissions i.e more than 3 per year

End-stage disease for whom hospital admission may not be the best option in the event of worsening dyspnoea


The patientand carer

The GP

Chest Consultant

Palliative Care

Consultant

Respiratory nurse

specialistPalliative care

nurse specialist

District nurses

Occupational therapists

Physiotherapists

Carers

Community matrons


In the last year of life 32% of patients dying

from COPD have three or more

hospital admissions

Elkington H, White P, Addington-Hall J, Higgs R, Edmonds P. The Healthcare needs of chronic obstructive pulmonary disease patients in the last year of life.

Palliat Med 2005; 19: 485-491


GSF Prognostic Indicator GuidanceThree triggers for Supportive/ Palliative Care are suggested-

to identify these patients we can use any combination of the following

methods:

1. The surprise question ‘Would you be surprised if this patient were to die in the next 6-12 months’

2. Choice/ Need - The patient with advanced disease makes a choice for comfort care only, not ‘curative’ treatment, or is in special need of supportive / palliative care eg refusing renal transplant

3. Clinical indicators - Specific indicators of advanced disease for each of the three main end of life patient groups - cancer, organ failure, elderly frail/ dementia


Breathlessness and anxiety are the main symptoms (but check for others)

Remember non-pharmacological interventions

Consider palliative care referral for any respiratory patient struggling with physical or psychological symptoms

Consider palliative care referral for all pulmonary fibrosis patients

ADVANCE CARE PLANNING!!!!!

Conclusions

SYMPTOM CONTROL FOR ADVANCED RESPIRATORY DISEASE

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